Feeling Discouraged- Heparin Drip

NurseOnAMotorcycle, ASN, RN · Dec 24, 2014

First breathe. Take a large breath all the way down to the very bottom of your toes and then slowly let it all out.

You are not a failure.

Hopefully you weren't left all alone with that assignment as a new 6 month nurse, especially with one of them being that sick of a patient. You should have had experienced backup as well as a two nurse check on that medication. If not, shame on that charge nurse for not double checking you on it or providing some kind of back up.

It's great that you learned something out of that and that someone caught the various mistakes made by the entire team. I can tell that you are not someone who doesn't care about what they are doing because you are really analyzing every aspect of the case. In this career the worst way to learn something is to learn through mistakes, but it does happen and it's never enjoyable when it does.

This will stay with you because you have been so traumatized by it, and when the new grad nurse comes along you will be their voice of experience.

I'm sorry that this happened but you'll be a better nurse because it has. Hang in there and treat yourself extra well for a few days. "This too shall pass."

FloatFNP-C, BSN, MSN, NP · Dec 24, 2014

Thank you for that. It means a lot. I am still in a puddle of tears hoping I didn't make a colossal mistake. It was doubled checked by the charge nurse, the heparin gtt was correct but I think the main miss was the PTT not being drawn before starting it, which lab assured me would be "added" on to his PT/INR labs drawn prior. They never were. Maybe it would have indicated that it shouldn't have been started in the first place.... but again, this is protocol for a doctor to order the heparin gtt and not know the PTT? I'm new, but that logic doesn't make a lot of sense to me.

You are right, whatever went wrong, it was a system wide error.

Loo17 · Dec 24, 2014

At my hospital when a heparin drip is started is the protocol for the nurse to draw a ptt just prior to starting the drip and then every 6 hours and titrate according to the pharm protocol.

Cook26 · Dec 24, 2014

First off, FFP is poorly indicated for reversal of heparin. If the INR was 5, this would most likely be because of his Coumadin, not the drip you started. FFP would in fact be correct for reversal of the INR caused by the Coumadin.

The correct reversal agent for heparin would be protamine sulfate.

That is why a PT/INR and an aPTT is drawn...different coagulation cascades.

Don't beat yourself up too bad. Obviously no one wants to do anything wrong. But, if something was missed, the patient is ok, and you learned from it, the outcome isn't that bad.

Lev, MSN, RN, NP · Dec 24, 2014

Hi all. Venting a little, but I do have questions.
Last night was awful.
It was def. the busiest night I've had in my 6 mo of nursing. Mainly, a new admit was keeping me really busy- big pleural effusion, on 8L simple mask (med surg floor BTW) and I needed to start my first heparin drip. I wasn't ENTIRELY sure why I was starting it- no evidence of clots, but did have a mitral valve replacement hx and was on coumadin. I can't remember was the PT/INR was but I think it was subtherap. Anyway, consulted with the Charge and they didn't have any real answers for me, the doc doubled mentioned on the phone to start the heparin drip but before I could ask why they hung up. Does anyone have any ideas??
The reason I ask is because when I woke up today I called to check on this patient because I was worried something was missed and I was informed they are now on FFP to reverse the drip because the pt really needs to get his lung drained and the INR was 5.
I am just confused and feel like I royally screwed up. Oh, and the lab and I both "missed" getting the PTT/PT/INR draw right before the heparin drip was started. The pt had labs drawn a few hours earlier with the PT/INR and I kept trying to ask if I am supposed to do anything- draw more labs?? And nobody could really help me.
I am thinking missing his PTT was very dangerous. But why would a doc order a heparin drip without knowing a PTT in the first place?
I am so confused and I feel like a total failure. Nursing is SO much responsibility and I'm feeling the weight of it like never before. Maybe I need a nursing job where I am less likely to cause so much harm

Doctors sometimes do stupid things. That's why we're here. And I say we because although you messed up this time you will never never make this mistake again. This is a good example of how critical thinking is developed. I didn't "get" the importance of knowing PT/INR before giving coumadin when I was a new grad. My preceptor always asked what it was before I gave it, but this was one if those things that didn't "click" til months later. Lessons for the future: (and I say this with respect for you as a new nurse who is self aware and seeking advice).

1) Always always know the reason for a therapy you are initiating.

2) Always know PTT along with PT/INR before starting heparin therapy. Heparin is dosed based on PTT but is important to know the INR because if both are increased the patient is at a greater risk for bleeding.

3) In addition, know which other anticoagulants or antiplatelets or NSAIDS your patients are on because they can all cause bleeding. If a patient was on arixtra sub q for dvt prophylaxis and they are started on heparin, the arixtra should probably be discontinued.

4) Lastly, know your platelet counts and watch their trend. If platelets drop abruptly or go under 100k you may need to DC heparin because it could be a sign of heparin induced thrombocytopenia or HIT.

FYI, if they were worried about an INR of 5 and giving FFP it means he got too much coumadin. Not heparin. The antidote for heparin is protamine. For coumadin, vitamin k (IV or PO) or FFP is given. I don't think the patient was harmed because of your actions related to the heparin. Unless his PTT was dangerously high and you hung heparin without knowing the baseline PTT.

It's kind of sad that although you asked your superiors at work you weren't given real answers. If I were you, I would call the doctor back to clarify or see if they left a note in future cases like this. Your work environment sounds quite unorganized and dangerous to say the least.

KelRN215, BSN, RN · Dec 24, 2014

PT/INR are not affected by heparin, so the heparin drip wouldn't have caused an INR level of 5. PTT should be monitored with heparin.

FloatFNP-C, BSN, MSN, NP · Dec 24, 2014

Ok... This is starting to make more sense. So the INR being 5 would still result in the heparin being turned off?

(which is was) but it's the PTT you really follow for heparin and the INR for Coumadin. I do recall this from school, too bad my night was so busy my mind wasn't on this level

FloatFNP-C, BSN, MSN, NP · Dec 24, 2014

Is it true that if his pt INR was high from Coumadin they were bridging with Iv heparin to still anticoagulate him? Because I gave vitamin k to try to reverse his INR. So he would still need something, hence the heparin. ?

Thanks for all of the advice and encouragement!

wyosamRN · Dec 24, 2014

Sounds like bridging prior to a procedure to me. Heparinize the patient, then reverse the coumadin. The reason you do this, is it is much faster and more predicable/controllable to "dehaparinize" the pt for the procedure, while still keeping them anticoagulated as much of the time as possible to avoid clots.

Esme12, ASN, BSN, RN · Dec 24, 2014

Is it true that if his pt INR was high from Coumadin they were bridging with Iv heparin to still anticoagulate him? Because I gave vitamin k to try to reverse his INR. So he would still need something, hence the heparin. ?
Thanks for all of the advice and encouragement!

Right now I don't blame you for being confused...I'm confused. I know that sometimes things are orders in a crazy way when the benefit outweighs the risk....but this baffles me a bit. If they were not thinking pulmonary emboli it must have been for the valve.

You were giving Vit K yet told to start a heparin gtt. I mean I kind of get it....but not really. I can see that they were going to start a heparin gtt to cover the valve....if it was a mechanical valve. The INR is elevated even for a valve (although some resources have shown benefits of slightly higher INR and mechanical valves) So you are lowering the INR (indicating the patient is slightly over anti-coagulated) yet placing them on anti-coagulation. It sounds to me like the right hand didn't know what the left hand was doing....I need more details to figure it out.

The FFP would be to decrease the PT/INR in order to do a thoracentisis and thereby decreasing the risk of bleeding...hence the use of the Vit K as well.

The heparin gtt...will further anti-coagulate the patient. The INR check coumadin....the PTT is for heparin.....in the future always be sure the coags are done and resulted before starting the gtt. If the MD still orders the gtt without results obtain a specific order to begin the heparin in the absence of the PTT.

((HUGS)) You did your best....I feel that your charge let you down in guiding you. For the future...look up your facilities heparin protocol. Do you have an order series/protocol order sheet to follow for titrating the gtt? Even if the MD hangs up...call them back. Yeah they might be a donkey on the phone...but who cares. You be sure to have your questions answered.

Second call....Dr this is Nancy Nurse on the 4th floor I'm calling you back about Mr. Pleural effusion. I am confused about the Vit K I gave and starting the heparin gtt. We do not have a PTT and the INR is 5. Do you still want the gtt begin without labs? I checked with lab and they said it would be added on stat....it is not resulted yet. His rr rate remains 24 on the 8L simple mask and c/o SOB I heard it mentioned about a thoracentisis in the AM.....do I need to plan or getting supplies for a thoracentsis in the AM? Will the patient need to be NPO? .....Dr's are busy with many patients....they do count on us knowing the patient so that we can remind them which patient specifically they are ordering for and try to prevent errors.

All this comes with practice....and your charge is supposed to be leading you in these situations.

Take a deep breath...forgive yourself. That you are asking and worried about it all shows you care and are learning.

Enjoy your holiday and days off (if you have any....hugs)